Healthcare is almost 20% of our economy. A future President Clinton or a future President Trump will, through executive action, have a lot to say about how that money is spent. Commonwealth fund (found here) has an exceptional comparison of the two candidates’ proposals and how they would effect the budget. If you care about fiscal responsibility, for the record, the balance sheet is found below:

So, the Trump plan is not, despite what he claimed in the debate, the way to fiscal solvency.

Kaiser Family Foundation has put together a specific list of issues (found here) that folks appear interested in and has evaluated each camp’s claims. The Cliff’s notes version is as follows:

Health insurance coverage and cost – Issues include overarching reform of health system remains unpopular in a partisan manner. Affordability hampered by a glitch where family coverage became more expensive, “cost sharing” was not controlled by the law, enrollment was not implemented well, and transparency provisions not implemented. Market place competition is limited, especially in rural areas.

Clinton

supports policies to maintain and build upon the ACA.

increase premium subsidies in the marketplace so no participant is required to pay more than 8.5% of income for coverage.

fix the “family glitch” and allow people to buy coverage through the marketplace regardless of their immigration status.

make a public plan option available in every state and give people the option of buying into Medicare starting at age 55.

invest $500 million annually in outreach and in-person assistance to enroll more uninsured in coverage, and she would enforce ACA transparency provisions.

authorize the federal government to review and disapprove unreasonable health insurance premium increases in states that do not have such authority, repeal the Cadillac tax.

proposed new private plan standards to waive the annual deductible for at least three sick visits per year, limit monthly cost sharing for prescription drugs to $250, and protect against surprise medical bills when patients inadvertently receive care out of network.

proposed a new refundable tax credit of up to $5,000 to subsidize out-of-pocket health expenses (including premiums in marketplace plans) for all Americans with private insurance.

Trump

complete repeal of the ACA, including the individual mandate to have coverage.

create high risk pools for individuals who have not maintained continuous coverage.

provide a tax deduction for the purchase of individual health insurance.

promote competition between health plans by allowing insurers to sell plans across state lines; an insurer licensed under the rules of one state would be allowed to sell coverage in other states without regard to different state laws that might apply.

promote the use of Health Savings Accounts (HSA), and specifically would allow tax-free transfer of HSAs to all heirs.

would also require price transparency from all hospitals, doctors, clinics and other providers so that consumers can see and shop for the best prices for health care procedures and other services.

Medicaid – Issues include states’ concerns regarding financing and unwillingness to expand to those too poor to qualify for a tax rebate required coverage

Clinton

encourage and incentivize states to expand Medicaid by providing states with three years of full federal funding for newly eligible adults, whenever they choose to expand.

would also continue to make enrollment easier and launch a campaign to enroll people who are eligible but not enrolled in coverage.

would cover the low-income uninsured through Medicaid after repealing the ACA.

The House Republican Plan, which is part of a larger package designed to replace the ACA and reduce federal spending for health care, would offer states a choice between a Medicaid per capita allotment or a block grant.

Medicare – Issues include prescription drug costs, fate of provisions in ACA, public option for those 55-64

Clinton

supports maintaining the current structure of the Medicare program and opposes policies to transform Medicare into a system of premium supports. On the issue of prescription drug costs

supports allowing safe re-importation of drugs from other countries, allowing the federal government to negotiate drug prices in Medicare, especially for high-priced drugs with limited competition, and requiring drug manufacturers to provide rebates in the Medicare Part D low-income subsidy program equivalent to the rebates provided under Medicaid.

does not support repealing the ACA or any of the Medicare provisions included in the law; rather, she supports expanding the law’s value-based delivery system reforms.

proposed to allow people ages 55 to 64 to buy into Medicare.

Trump

No position on the issue of Medicare program restructuring or whether to allow older adults ages 55 to 64 to buy in to Medicare.

supports repealing the ACA, which would presumably mean repealing the law’s Medicare provisions.

supports allowing safe re-importation of prescription drugs from other countries.

Prescription drugs – Issues are pricing (generally more expensive in US than in other countries despite being manufactured in the same facility) and out-of-pocket costs (many plans have gone to a cost sharing rather than a deductible strategy

proposes a $250 per month cap on cost sharing for covered drugs; and a rebate program for low-income Medicare beneficiaries that mirrors those in Medicaid.

Trump

supports allowing importation of drugs from overseas that are safe and reliable but priced lower than in the U.S.

supports greater price transparency from all health providers, especially for medical exams and procedures performed at doctors’ offices, clinics, and hospitals, but does not specify whether this policy would also apply to retail prescription drugs, which typically are not considered services or procedures.

Opioid epidemic – Issues include increased use (1 in 20 nonelderly adults used opioids for nonmusical purposes), increased addiction ( 2 million non elderly adults with of the level of opioid use increases to the level of opioid use disorder, often referred to as abuse, dependence, or addiction), increases in overdose deaths (those involving opioids have quadrupled since 1999).

Clinton

released a $10 billion (over ten years) plan to fight drug addiction.

includes a federal-state partnership to support education and mentoring programs

development of treatment facilities and programs

efforts to change prescribing practices, and criminal justice reform.

direct federal action to increase funding for treatment programs

change federal rules regarding prescribing practices

enforce federal parity standards

promote best practices for insurance coverage of substance use disorder services

issue guidance on treatment and incarceration for nonviolent and low-level federal drug offenders.

Trump

Will build a wall on the U.S.-Mexican border

will help stop the flow of drugs and thus address the opioid epidemic.

supports policies that protect and expand women’s access to reproductive healthcare, including affordable contraception and abortion.

defends the ACA’s policies, including no-cost preventive care and contraceptive coverage. promised to protect Planned Parenthood from attempts to defund it and would work to increase federal funds to the organization. called for the repeal of the Hyde Amendment which she believes limits low-income women’s access to abortion care.

would appoint judges to the Supreme Court who support Roe v. Wade, ensuring a women’s right to choose an abortion.

would also repeal the ACA, which would eliminate minimum scope of benefits standards such as maternity care in individual plans and coverage of no-cost preventive services such as contraceptives in private plans.

I am teaching a class tomorrow entitled “Health Care Reform” to the first year medical students. I pulled out my slides from last year (January, had just come back from DC, was convinced that we would have something on the President’s desk by July) and made some changes. The good news was that I only had to add a couple of pieces of information to the talk. The bad news is that we don’t have change yet, but it may be closer than we think.

Why don’t we yet have health care reform? There was an article in the New Yorker several years back that did a very nice job of describing the concept of moral hazard and why there is a policy dispute about health care as a social good. Gladwell points out that many feel (most fall on the “conservative” end of the spectrum although not all) that the uninsured who pay cash rarely have no health care expenses and the very wealthy spend a lot on health care. In a market system those paying cash are paying closest to the true value so it must be that those who are wealthy view health care as a luxury item. It would not be morally right to give all Americans access to this luxury.

The RAND corporation performed an experiment in the 1990s to see whether this would be the case. They found:

In general, the reduction in services induced by cost sharing had no adverse effect on participants’ health. However, there were exceptions. The poorest and sickest 6 percent of the sample at the start of the experiment had better outcomes under the free plan for 4 of the 30 conditions measured. Specifically,

Free care improved the control of hypertension. The poorest patients in the free care group who entered the experiment with hypertension saw greater reductions in blood pressure than did their counterparts with cost sharing. The projected effect was about a 10 percent reduction in mortality for those with hypertension.

Free care marginally improved vision for the poorest patients.

Free care also increased the likelihood among the poorest patients of receiving needed dental care.

Serious symptoms were less prevalent for poorer people on the free plan.

Cost sharing also had some beneficial effects. Participants in cost sharing plans worried less about their health and had fewer restricted-activity days (including time spent in seeking medical care).

In addition, the experiment examined whether shouldering more of their own health care costs leads people to take better care of themselves. It did not. Risky behaviors were not affected — rates of smoking and obesity, for instance, did not change.

(An article in this week’s New England Journal of Medicine finds that increased cost sharing on the outpatient side in Medicare patients leads to delayed care and more hospital care as well. People tend to be penny wise and pound foolish when it comes to their health. A lesson learned in the 1930s and one of the reason that a group of physicians founded Blue Cross)

Mr Gladwell points out that the real objection to universal coverage, from a policy standpoint, is that some people (those with disease) will consume more resources than they will have been predicted to pay for. In other words, the objection is that resources are redistributed from those who are healthy to those who are unhealthy. Susan Channick expanded this in an article on why we will never have a single payer system in this country. She lists the reasons as inertia, path dependence, the expense of the Medicare program, the American belief in looking to the private sector for solutions to even large social problems, the fear of big government coupled with the belief that government is the problem rather than the solution, the political preference for incrementalism over fundamental change, and cultural beliefs such as the belief that while all Americans enjoy equality of opportunity, only those able to capitalize on the opportunity are entitled to enjoy its fruits. This last one is the most profound, as the implication is that we Americans who are healthy deserve to be healthy and owe nothing to our unhealthy neighbors.

In an article in the New England Journal, Thomas Murray points out that the Judeo-Christian tradition as articulated in the Bible includes the concept of “stewardship.” He says that “Landowners are instructedin Leviticus: “When you reap the harvest of your land, you shallnot reap to the very edges of your field, or gather the gleaningsof your harvest; you shall leave them for the poor and the alien.”The obligation is not limitless: the landowner does not haveto prepare a meal for the “poor and the alien,” does not haveto surrender the entire crop, and should protect the land toensure that it remains productive. But when food is more thansufficient to feed all, allowing some people to starve is indecentand represents a failure to live up to universal moral duties.” Lets all try to live up to that standard.